Clinical Review

Of TV ? ? ], 8hot W lslon of the Tibia, for the cure of Deformity occasioned by a SCt' ^a$e 0f?Qnd ' Charles Aston Key. (With Plate). l>m ? i. ~Permatocele, or Varicocele, treated by excision of a portion of the Cat0bs^vLrransby B* CooPerF-R-sTi Hen l ns 0n Abdominal Tumors and Intumescence ; illustrated by H first r DiseaseBy R. Bright, M.D. F.R.S. (With Plates.) Prs 'U tlL Per to which we shall allude is that by Dr. Addison, which, indeed, he volume.

INo. Viil. April, 1839. indited by (Jeorge H. ' RI'?W> M.A., &c. and James P. Babington, M.A. &c. pr Tl,1' thenn^Gr 0^ers t^ie following physiological and pathological carte:? >as a.,-,. Ulsorders of the Brain, connected with Diseased Kidneys; by S l?nPe f1S?n-M-D- ' ? cans r Conn^?Int out *he general character and individual forms of cerebial intcted with interrupted function of the kidneys, from whatever pted function may arise. Secondly, To shew, that, in recent pr0rJ-?nic disease of the kidney, the cerebral disorder is not unfrequently Cas?s ly, To and occasionally the only obvious symptom present. And Th' ^Pon th a "sh a means of diagnosis, in such obscure or in unsuspected has ]6 rec'proc FeCuliar character of the cerebral affection." to Sn?^g been k action of the brain on the kidney, and the kidney on the brain, Jiid1"1 2. A sudden attack of a peculiar modification of coma and stertor; ^ be temporary or end in death.
TniD8^1" 3. A sudden attack of convulsions; which may be temporary or ter death. 0f c 4. A combination of the two latter; consisting of a sudden attacK and stertor, accompanied by constant or intermitting convulsions. ?ness,?K 5. A state of dulness of intellect, sluggishness of manner, and droit's1.^ mi preceded by giddiness, dimness of sight, and pain in the head; procee . g$ to coma alone, or to coma accompanied by convulsions; the coma PreS , peculiar character already alluded to.

cf:ed
With respect to the first-mentioned form of cerebral disorder c0Iin^abl)T t renal disease, that of quiet stupor, it is, in its most exquisite form, Pr t(jra'',f least frequently met with ; the face is pale, the pulse quiet, the pup? at least obedient to light; and although the patient may lie almost a for SJ motionless, there is no paralysis ; for, on attentively watching blTX? tiflS ,t time, he will be observed slightly to move all the extremities. By ag1 e0t,' and speaking loudly, he may sometimes be partially roused for a na? se quickly relapses into stupor, as before; or it may not be possible to rvU]si?^ at all. There is little or no labour of respiration, no stertor, and noco ^ for^ Slight degrees of it occasionally precede and pass into the next or sec ^ c0it This second form of cerebral affection is that of a sudden attac ^ fto with stertor, or, in other words, apoplexy : it is, nevertheless, din? u5|L ordinary apoplexy: it is the serous apoplexy of authors, and presents ^ general characters of cerebral affection depending upon renal diseas pa^ face, instead of being flushed, is, in almost every instance, remar, iv qU^'jj the pulse, though sometimes small, and more rarely full, is remarkab y *e<>' almost natural ; the pupil, also, although occasionally dilated or C?D often remarkably natural in size, and obedient to light; and there is D.?s apt When the labour of respiration is very great, the general character lS . 0{ ^ modified by an accelerated pulse, and occasionally by a slight patiefV countenance.
The coma is for the most part complete, so that js cannot be roused to intelligence for a single moment. The sterto^ a^ct' peculiar, and in a great measure characteristic of this form of cerebra d connected with renal disease: it has not by any means, in general ^ s|jgP ? rough, guttural, or nasal sound of ordinary apoplexy: it is sometiff1 of this kind ; but much more commonly the stertor'presents more o character, as if produced by the air, both in inspiration and in rat J striking against the hard palate or even against the lips of the Pat1.6 t]ie.ed than against the velum and throat, as in ordinary apoplectic stertor . 0bsefV^ respiration, too, is usually, from the first, much more hurried than P ^ in the coma of ordinary apoplexy. The peculiar stertor coupled w1 c0pfioe face has, in more instances than one, enabled me to pronounce wit i l839] ^vWh u0 re ? he renal, without asking a single question, and in cases, too, in third f ease whatever had for a moment been suspected.
U(^den a^t ,?rr*) ?f cerebral disorder connected with renal disease is that of a r0^ Part rC ? i convu^s,ons-1? this case, also, the countenance i3, for the , Pupil';15enla a^l>T Pa^e? although occasionally, slightly flushed at intervals: w^times si ? ^ affected : in slight attacks of the kind, the pulse is of n there -ng arty quiet; but when the convulsions are severe, and especially ftetl sympatl a ^esree ?f coma as to be attended with stertor, the heart aft?! ?f cer k"ZfS* an(^ the pulse becomes rapid, irregular, and jerking. This j/^tion shall i a^ect'c,n often passes into the fourth variety ; or the cerebral latter 0n ^orm 0 ^le f?urth variety from the commencement: to c?niaCa^e W-G ^ave merely a comhination of the second and third varieties d ^ther as' rr'e^ breathing, stertor, and convulsions being so blended Resig1ated an *? ^ave a dispute, whether the affection ought to be jjjend be V(f ?f y or epilepsy. From what has been already stated, it may, in ^?r' connn / eas}ly recognised as one of the common forms of cerebral disa e fifth ? with renal disease. telT?re 8rad)Valle^ '-S t^iat *n which the cerebral disorder makes its approach in ann ' an^ 'ns'di?us manner, usually commencing with dulness of into ^Ofe Qp | ness of manner, and drowsiness, gradually proceeding to coma, f.^ tirjie G^S stertor, with or without convulsions ; these states being, at the jnrtti of Ce'r 'Anguished by the general indications already pointed out. This is Progr a* ^'sor^er appears to be that which most commonly supervenes WSS m?rbid change of kidney described by Dr. Bright; and highly ently Preceded by giddiness, dimness of sight, and pain in the head." that'0tl betv'Qterest'nS question is?whether there really exists any discoverable ton? ^e? in 4^ character of the renal and the cerebral affection ? And if sUft; ? f?rme > relation are the forms, violence, and permanence of the latter fact-' ^ur author acknowledges that he is not yet in possession of jio Ittlagines tv> *? jUstify any very positive conclusion on these points, although i*!8 ?f the f ^e has perceived a certain degree of relation between the affecrei) ^ all th organs\ clUi ^'^ase6 more serious affections of the brain arising in connection with of5'1 sVre' mildest form appears to be that of a tendency to a state of hfelled * Varying in degree from a mere torpidity of manner and sluggishness be e foiind'^. CornPlete insensibility to all surrounding objects. Accordingly, I ki/^rded form ?f cerebral disorder most frequently present in what may tj, Qey. -j>h aS ^east formidable, or more temporary derangements of the Stir]6 present?ira0St ex9uisite example I ever saw, occurred in a man who at the the Had n? droPsicai symptom whatever, whose urine was not albuminous, 4L c?rtical 6 00 coraplaint of pain or uneasiness in his loins. After death, J* "?= Mneys was found highly injected, of a deep-red or ?a al e strong6 ??l?ur> and somewhat softened in its texture; in short, furnish-S? ^y b^rSt 'n(hcations of a recent nephritic attack in a subdued form : it same state of things not unfrequently takes place, at bec i?n of l Progress of scarlatina : we observe an approach to a similar ai)(l?^e Over d^ln 'n cases fever> in which the bladder has been allowed to Or : 1,1 cases is*ended ; and most assuredly in cases of retention from stricture, ^d'k^iftienf ,Ca^culus in the kidney. In all these instances, the interruption le8s elce, rJr , *he urinary secretion may be said to be recent or incomplete ; Pas ^eril 'to ??a^'y the less degree of severity of the cerebral affection, and the S ?^y, a Patient; for in such instances the symptoms very commonly the?ri?inaily *^e patient recovers. When, however, the hurtful cause is of ^aUse 0f ^Phritic character, the chance of recovery will be less than when next, j stl'.uction happens to be merely mechanical and temporary. n Point of severity, of the cerebral affections connected with renal R 2 1 244 Periscope; on, Circumspective Review.
[July disease appears to be that of convulsions, with comparatively little ste ^ je.
convulsions, however, which may prove speedily fatal; or which r peated an indefinite number of times, but from which the patient very ^ completely and permanently recovers. Accordingly, I have observed t ^ of more simple convulsions most frequently associated with what may ^at jus' regarded as a more exquisite and enduring form of renal disease than ^ealluded to : I have observed it most frequently in cases of renal drops}'; ^ quent to scarlatina; and in that form of renal dropsy supposed to an direct exposure to damp and cold, and commonly known by the name oi matory dropsy. As the renal afFection has already proceeded to induce ^5 we cannot but regard it as more fixed and more formidable than in ,^\1> described as being attended with more or less of quiet stupor : andacco jgjj# instead of merely a certain degree of this latter condition, we have c?n atie#t which may indeed prove fatal, but from which, as already observed, the P often completely and permanently recovers." The most stubborn and dangerous cases of cerebro-renal affection ar?
where the structure of the kidney is irrecoverably disorganized in the described by Dr. Bright. It is not true, however, that every such caf6 re tbe sociated with cerebral disorder?on the contrary, many cases occur ^jCoiD' sensorial functions remain unaffected till the very last period of the re?a ^let" plaint. What it is which causes this discrepancy, we are, at present, u ctio" ascertain. It has appeared to Dr. Addison, that when the cerebral a eocf' does supervene on this fatal form of renal disease, its constanc} ', u ? and intractability correspond with that of the primary malady.
nvi?e5?' " The patient suffering repeatedly, or more or less constantly, frooo he drowsiness, giddiness, or pain or sense of tightness in the head, an peculiarly liable to be suddenly seized with the most alarming and ta?s}-sBg&' all the forms of cerebral disorder occurring in connection with renal d'3 profound coma and stertor, with or without convulsions." , or?
The post-mortem appearances in the brain are passed over by our 0f ^ they are very often slight, and apparently inadequate to an explanation symptoms. (1'0(V eXerci undergoes after being raised above its natural number by SeJ ?r mental excitement, the effect of long-continued rest, in |. .^tion ev at may he termed its normal frequency, has not attracted much n, of fu11 ^rorn those who have most carefully investigated the diurnal revoa a rf ')u'se* ^ we take the frequency of the pulse on first rising in the th^da'rd f efore it has been subject to the excitement of food or exercise, as ffequen comParison, we shall find that continued rest will greatly reduce I H We anC^' . aSain, after the pulse has been increased in frequency by be * aQd tl?^V ^ t0 suhside to the numher which it had before the food was ^h'0tQes less ^ con^nue f?r a considerable period in a state of rest, the pulse ill 'C^ 't had an^ 'CSS frecluent' till it reaches a much lower frequency than that th^^tes th" ?n ^?r?t fisinS in the morning. Pkriscopk; ok, Circumspective Rbvibvv. l respect the morning. I thus obtained two series of observations, in every' analogous, and admitting of the most exact comparison. That no err at creep in, I not only remained during the whole time of the ?^serV' estu^ rest and in the same posture, but I took care to pursue precisely the sa in the morning as in the evening." Omitting the table of results we will insert the summary of them.
?. It appears that the pulse is less frequent late at night than at nin ^ from four to six beats ;* and that during the same interval of time it fb' rapidly, and attains a lower frequency in the evening than in the mornii B f (jie difference, indeed, is in no case very considerable, but it is remarkao ^ uniformity of its occurrence; and it is well worthy of remark, that eacD difference which occurs in the mean of all the observations takes P separate series ; a circumstance which, as it is rarely met with in e*P on the human body, will inspire the greater confidence in the resultsi" In five out of the eleven series of observations, irregularities were ob the morning ; that is to say, the diminution of the pulse was not PT?le but an occasional increase of frequency took place. In the evening* nution was, in every case, uniformly progressive.
r?tee^ b. Out of fourteen observations, there is one only in which the imme 1 oD]y W of the meal was greater in the evening than in the morning, and ^entjje M' one beat; and one only in which the effect was equal at both times in. jo to whilst in every case, without exception, the effect was of shorter dura evening than in the morning. But by far the most remarkable fact e sestp by these observations, is, that the same food which in the morning\ frequency of the pulse from five to twelve beats, and keeps it raise1d " natural number during from one to two hours, may in the evening Pr effect whatever. 3. The diminution of the frequency of the pulse is more regular gressive in the evening than in the morning. . n in^5 4. The effect of food is greater and more lasting in the morning t 0 evening ; and, in some instances, the same food which in the morning. r^1 an effect considerable both in amount and in duration, has no effect W the evening. ^ Dr. Guy is evidently possessed of a clear head and of professional ze -^uU0 useful qualities lead us to expect, and will enable him to present, c?nej. to practical medicine of greater value than those which he has yet oner W III T&e so pendulous, as to reach at least a third lower than on the opposite si ^jD slightest manipulation produced considerable pain, both in the testic , ajl tbc the course of the cord ; and the testicle itself was wasted, and exhibi usual signs of an irritable condition. " The patient complained of a constant sense of weight, attended wi j0[dS/ dull pain, extending from the testicle, along the spermatic-cord, to . pair*" with an habitual feeling of restlessness and anxiety. His appetite was i ^ tbe and a constant depression of spirits induced him to seek medical relieff usual remedies had been employed, as purging, recumbent posture, sus>p bandages, and cold applications ; but ineffectually. On questioning to Qf tW as to the probable cause of the complaint, he could attribute it to $0$ usual local causes, as a blow, &c. but admitted that he had always t> ^ or less affected with a constipated state of bowels. I therefore pr?P?seej ji#' that he should return into the country, submit himself to the continu ^cis1' ence of purgative medicine for a short time, abstaining from all violen ^ ctf> and that if this plan did not remove his disease, I would attempt a ra by the operation of excision of a portion of his scrotum. To this acceded; seeming willing to submit to any temporary pain, rather tot& his protracted suffering. He therefore returned home, strictly adhcr jjitfl" prescribed discipline for six weeks: at the end of which period, fin ff0 4W self in no way improved, he came to London, determined to u*1" operation." jo * On the 8th of February, Mr. C. excised a portion of the scrotu following manner : rthe^ A' * 0 e m tightly between h'sjj ^ middle finger, so as to press the testicle closely against the externa1 ^0^ " The patient being placed in the recumbent posture at the foot the enlarged veins of the left spermatic-cord were emptied of their blo? a" Mr. Birkett drew the relaxed skin of the scrotum tightly between hlSrjDg middle finger, so as to press the testicle closely against the external ^ the back of his hand. I then, with one sweep of the knife, removed geptfll of the skin restricted by Mr. Birkett's finger, taking care to avoid t scroti: and thus exposed the tunica vaginalis, from which alone the i now received any covering. The bleeding being very inconsiderable, ajsiiig^f ately proceeded to bring the edges of the incised skin together, by r lower portion towards the upper; and maintained the coaptation & four sutures ; by which means I diminished the size of the left side 0 tjieD 6 \<> turn, so as to form a close envelop to the testicle. The parts w'ere, ported by adhesive-plaister and bandages, pretty tightly applied ; and , was enveloped in cloths kept constantly moist with cold water." . ^ te^\.
Some degree of inflammation of the spermatic cords, and of the rIS jjgtf ^ followed, suppuration occurred in the wound, but on the 4th of convalescent. The  ?rc*er to bring the leg into a more perpendicular line of bearing, a ^ anDey limb was great, to the full extent represented in the draw-t}jCo^siderab]are^ ^r.ora history of the accident, and subsequent treatment, that Ca^ rolce^ e ?fl P0rti?n of bone having been lost on the inner side of the tibia, theS! as an Xt had united at an angle, in the same manner, and from the same for atlteri0r erated spine acquires an irregular form from loss of substance on al an a ^art ?f vertebrae. The upper part of the tibia had not only 50 ^eviated fG at -its P?int of union with the lower portion of the bone, but r?m its natural line in relation to the femur. Its head, with the Pkriscopb; or, Circumspective Review. earaoC{ articulatory surface, had been somewhat forced outwards, so that an app ^ of obliquity was given to it when viewed from before. In addition to eJ.
deformity of the tibia, the fibula had undergone a displacement at its tjbia, tremity. Its head had been forced away from its articulation wit.h ce10 and formed an unnatural prominence, above the usual position, in re ^og> the tibia. The bearing of this bone was also altered, as appears in the ^ Not having been broken at the time of the accident, it could not yield a an angle, as the tibia had at the seat of fracture; but maintaining 1 ? jjance straight line, it had been compelled to alter its line of bearing, in c?ve(J a with the angular form of the larger bone. The fibula, therefore, preser acted o" parallel to the lower portion of the tibia. Its lower end, being forcibly j jje by the inward inclination of the foot and lower part of the tibia, had 0?' upper part outward; and had caused a dislocation of its head, whic.tur^ dergone some change of form, and possessed a degree of motion not n jjjia it in its ordinary position. The shortening of the whole limb occasion^ ^3; alteration in form was such as to cause Captain Charlton to walk on ^ ^ the heel being raised an inch and a half, when he stood upright. The s, had a healthy aspect; and the cicatrix over the bone had not e? ^ct'f a firmer union to the periosteum than is usual with wounds situated over bone." ibia, BfiJ This description might, perhaps, be simplified by stating, that the 1 j3U the junction of its upper and its middle thirds, formed an angle of betw and 140?, salient outwards. ^ reful e^3 nation of the limb : and after hearing the history of the accident, anC*'!d ^ On the 10th of October, Sir A. Cooper made, with Mr. Key, a caretu c0d< sequences, he decided that the limb might be restored to a useful state, "le3tora' the deformity might be remedied. He  the groove of the outer director, and from thence to the groove of the ingavV ifH its point being brought to view by a pair of dressing-forceps, the t W adjusted so as to cut the bone from behind. When the tibia was a ^ sawn through, the saw?as chain-saws too often do, even when ligh ^plet locked, and became useless: the section of the bone was therefore from before, by a small common saw. ot ju ""l As soon as the tibia was divided, Sir Astley Cooper, taking the f?
.oJJ> tfi hand, found the lower part of the leg quite free to move in any diree ^ag that it was unnecessary to divide the fibula. As soon as the tibia was ^ j 5 into a straight line, the head of the fibula was restored in some measu 1839] Imperforate Uterus.
Hns the0^100'-anc* ceaset^ to project in the unseemly manner it had done bones Pera^on* The part where the tibia was divided gaped, as soon as Sfthe tibia ^ StraiShten^? anc^ the point of contact between the sawn ends pd, fr0la was but a small portion of its outer circumference. The muscles !? ?vercom Gfh ? acciuired so fixed a state, that some force was required y 'Utted t?r resistance: for as soon as the hand was removed from the foot, Umb y car"ed it inwards, to its former position." ^blisije(j ^ a^owe<^ to remain unconfined on pillows, until granulation was lts several "t enc* ab?ut ten days the wound had quietly gone through ?entre ? ti.
a8es? and had healed, with the exception of about an inch in the ^althy p(,ls Part continued more or less open for some weeks, discharging a I limb' S'ving exit to a few minute portions of exfoliating bone. nee straight-ouShout the whole treatment, was kept upon the heel, with the 8t)V? embrace At first, two long lateral splints, well padded, were applied, so ^ ?-C,e f??t on each side: to these were added, afterwards, an under ieQ(WCy ^ore effective support and steadiness to the limb. The constant atldage3. lsPlacement was not effectually prevented by common tapes and JJd thns ma?.^ese became slack, the leg assumed its former distorted position; } limh? Was ?iven to the broken ends of the bone, in adjusting the line ,atHlages " To avoid this, which was not practicable by means of straps or ieVer |?Urniquet was applied at either end of the splint. The length of t ^'t in a uPPer tourniquet to act with great power on the foot, and to ? '?be heel /a'Sht line with the thigh. The lower one was kept firmly screwed sNilless of the two splints; thus keeping the foot firmly secured, and giving morning. The pulse was quickening, the skin was hot, the vagina was j^iD# hot and dry. We deemed it advisable to wait no longer: therefore*^ 0riemptied the bladder, I introduced two fingers of the left hand as far a5.arJs fice; and, upon them, a blunt-pointed bistoury, guarded with linen ?Tt o< handle, so as to leave no more than about three-quarters of an inch fre the extremity. This portion being turned upon the edge of the cicatu carefully divided, as in the manner recommended for the division of a stricture.
s co"5' The instrument was three times thus introduced, before the section ^ j pleted; and, at each step, both Mr. Lever and Mr. Batcheler po progress made. Altogether, nearly an inch in length was divided: a blood followed, nor did the incision occasion any pain. c3us?S Having proved, for we conceive it is proved, the value of inClS.V?at iticf of occlusion of the cervix uteri, Dr. Ashwell next attempts to proye c'xcejS may also be practised with advantage in cases where the os uteri is rigid. * *839] On Incision of the Uterus. 255 " It j11 ^ese monr0t suPPose(i that I recommend the knife to be at once employed S P?ssible t0G] cornP^cated maladies ; but I am confident?so far, at least, as it ?Ul(3e?-that 1? con?dent, 'n cases where a high probability must be our only ^reventecl bvT G' resuIts have occurred, they might often have been Ppended ca lmf^7 *nc>sion of the parts. But it has too often happened, as the h a too n6S w> either that the operation has been performed too late, or a^Ural effojV^1^ dilatation by the finger, and an unwise reliance on the J^Us>on wiif ve. together superseded its employment. Examples of entire ??re raie th c^sease> I^e those to which I have already alluded, are much a found nui?n extreme rigidity of the cervix and a diminished os : nor will it v e Precise n 6 S? 6as^ *n latter? as in the former class of cases, to determine ^ to t]le ?ment when bleeding, diaphoretics, fomentation, and delay, are to sQo^Vti at)(j .Use the bistoury; still the general safety of incision, and the ?ught t t^lnent danger of protracted and severe uterine effort and contuj Usal 0f 0 lnduce an earlier, rather than a. deferred operation. A careful W?Scarcelv f ^ases.and authorities appended to this essay, especially Smellie's Qj. ,ere the div^1-*? *raPress this conviction. In every instance, or nearly so, n "^tomaK 'S1?n moi"bid structure has been made prior to the occurrence t SS'^e bad ?n anC^ s'nk'ng' ^ has succeeded; and, generally, with the fewest J? to tl^ SymPtoms-Where, on the contrary, violent uterine action, [July ucces5 that bleeding and every adjuvant remedy have been fairly, but ,unS, e ctfitt tried, Dr. A. believes that we ought not to hesitate about incising p^0 where the violence and frequent return of the uterine effort threatens r the womb. If there be distressing and constant pain about the nec ^ a0d of the uterus, or in any other part; if the countenance becomes u ^jck, dark ; if perspiration issues at every pore, and the pulse is full, s*r.pg sotfe' and incompressible : and if these symptoms continue, although PeF ^ recoUrs? what lessened by bleeding and antimony ; there can be no doubt tha ^ juriDg should be had to the incision. It is impossible to fix a precise lirn^anDot which a patient may be safely left to her own unaided efforts : time the sole ingredient, although an essential part of every rule, regulating10 in obstetric cases. , 0IJ anc! "The operation," he remarks, "in any of the cases, whether it pe -ve ap" firmly closed, yet without organic change?or on an os very contracted, with or without surrounding disease, but entirely undila generally, easily performed. A probe-pointed knife or bistoury is ment most safely used ;?the woman\lying, either on her left side ?ron rrjed ^ close to the edge of the bed. The forefinger of the left hand is to be ? 0ry>5 that spot of the cervix intended to be cut: afterwards, the knife or bis to be cautiously conveyed, along the finger in the vagina, to the SP? cfljrft1 mentioned ; and if its point be gently pushed against the uterine st' (h will completely incise the parietes. In Mrs. Purcell's case, I carried first of all, forwards, toward the neck of the bladder (which was en3?0'n 'ab0^ fully avoiding it; afterwards towards the sacrum, making an indsl? ^ two inches long. The liquor amnii will necessarily escape as soon incision is made. The instrument may now be carefully withdrawn, and t ^oti dilatation left to nature. It is scarcely to be expected that all rend'n=eIiei# be avoided ; but the extent of the tearing is, as has been already stated^ S ^ttc confined within the limits of the vagina. I have no experience of effect of a crucial incision, in preventing extensive laceration ; but I rjng 0 ably inclined to it. It is not probable that much blood will be lost d ^ fret1 hy pressing that tumor backward, the other hand clearly por'i^'"' of c 8 connection with the loins. The part in which the tumor ia %'0tl ?fthe?Ke' Var^ accordinS to nature of the disease, and to the lar.3^1ce 0f fi ldney which it occupies ; and in some cases, where the whole % Ifrorn^i?r^an's so d'seased as to contribute pretty equally to the enkid 0'ns-Tl beginning, the hardness or tumor will be early detected in le^ey may beU\ !vve find, that a rapidly-increasing fungoid disease in the right ^i||'0tl Pus ? y perceived pushing its way beneath the liver ; a large col-5ssi ^r?^ably k?r other accumulation, enlarging the natural cavity of the kidney, Cti 8>ce e yt most distinctly towards the anterior part, and, from the iog 4 ; w?ritati?n. w'h occupy a place between the umbilicus and the <iisf4comParare'.?n contrary, a kidney enlarged by numerous cysts, afford-tlj^^tly fe[j. 1Ve y solid and uniform increase to the whole organ, will be most ki(j0 Part. jt?C(:"Pying the lumbar space, and giving solidity and firmness to *)?' ?r att L hkewise be found that when inflammation has pervaded the lci(Jr) ' and ^ ^le external part, it will be bound down to its natural Q eV often d C0mPletely fixed in the loins; not advancing, as the fungoid f0l> ^^rgefj,068' towards the anterior part of the abdomen." diJH f0r ent of the right kidney may be mistaken, if it makes its way Wi) Se p..en'argement of the liver, for pyloric disease, for a glandular T of fi sson's capsule, for disease of the colon or caecum, or for en-Usto ^'^ingujsu ?vary or uterus. sha]i a^end ^ from enlargement of the liver, Dr. Bright judiciously advises Proba^j 'ts relations to the ribs. If the liver, he remarks, be healthy, we b^|nS fairly 'n^ ^at the tumor, as the patient lies on' his back, instead of thern aUn,der the ribs, dips downwards, so as to allow the finger to lie "Ver to th uPPer Pai't ?f the tumor. Again, we seldom have disease the h sy&ipto C ex^.ent which is here supposed, without producing some pretty DjeeP Col0ur j!' either in the colour of the eye, or the tinge of the skin, or in ?f th? rthe ur*ne? or the diseased secretions evinced by the stools.
^ttp6" It see er may he combined with that of the kidney, as in malignant Po,siKr, ?f very rf ito us that, under such circumstances, a precise diagnosis is a c?1ta hatsl/ ] conse9uence-^ut Dr. Bright hopes that even here it is PeCuijln PUs, and? ^le ur'ne he altered in its character, more particularly if it ^ Per^ ^ard tul 'n add't'on to other symptoms of hepatic affection, should the the tjj CePtible u ^ra' which, under such circumstances, often form in the liver, ^certS?ases. Tvr the ribs, we might come to a correct diagnosis as to both te*tinain^g by th ma^' moreover, in this case, derive much assistance, from ^<1 ?eS' ^?r alth ^ and hy percussion, the exact situation of the hollow in-W tj!^ ?f them ?u^h it is true that they suffer great displacement, yet, if we 6 tumor danterior to the tumor, and lying over it, we may generally infer mo. Lx-aoes not form a part of the liver ; as it is very improbable that 258 Pkriscopk; or, Circumspkctivb Rkvievv. [joiy iiave such a growth should arise from the concave surface of the liver, as to portion of the intestine in that situation. en^0 The caecum and ascending colon are liable to disease, and to enlarge? joDaliy from the presence of flatus and from accumulation of feces, and oec^^ctio11' from other accumulations.
In all these cases the disturbance of the ^^jll of the large intestines will furnish useful assistance to our diagnosis.
in cases of flatulent distention, ascertain the fact by percussion, and by alterations which the tumor undergoes. In cases of faecal abscess, a dis ^p.
common from lodgments taking place in the vermiform process, the fi/' toms generally run much higher than in renal tumors: there is of't? foflD inflammation, and much tenderness; and, above all, the tumor is ot Pr' too low in the iliac region to be probably produced by the kidney* j mi#r Bright has known such abscesses discharge their contents almost in 0f^ region. In cases where concretions have formed, occupying a large p01? jo0k caecum, considerable difficulty may arise in the diagnosis, if we si^P ^^ the tumor ; but the disturbance of the bowels, the intense abdomin^ P tormenting collection of flatus, will be our guide. , Perhaps, says Dr. Bright, the most frequent mistake is to consider 7 kidney, an ovarian or uterine tumor. The history of the disease ^sCtW patients is fallacious. Dr. Bright contributes some "hints towards their nation. tit'5 "I "The present situation of the tumor will enable us to discover tha connected with the pelvic viscera; and usually there is a distinct s . which the hand may be placed, between the tumor and the pelvispoint to be attended to, is, the situation of the hollow viscera; which*examination, will be found to overlap, or to pass over the surface f r t0 d'r' ?and this, together with the history of its growth, ought sufficient'/ ffflt( our judgment. Occasionally, the ovarian tumor assumes such var'etieBe to fj as to deceive the most experienced : and an instance very lately cal 0^. knowledge, when several, who were consulted, altogether denied t?e origin of the tumor, and ascribed it to the liver ; though, after death* out to be ovarian. In this instance, the absence of any hollow v'scerf?lt lejS < to the tumor would have prevented the supposition of its being kidn^'.^y W though the same might not hold good as to the liver. When the descended almost to the pelvis, and approached the middle line of the ^ 0f v it has been mistaken for uterine tumor ; but an examination of the n ^ in uterus, and of the uterus itself, in the usual way, will come in aid ot ^fin lf* in c?* 'S caPa^le of bringing us to such conclusions, so the history the I Us ftearl)njUnct'on witb tbe Physical or local* and general symptoms, may e ^ Whidf t0 same point:?and I will now proceed to refer to some of ^ith ? two1 ma^ serve to guide us in the inquiry." ^eUi eased iS--raPt?ras, most remotely connected, in the majority of cases, Helra' Neitlldney' are haematuria and the passing of small calculi by the It-^e chan ^ ne.cessarily indicates or leads to organic alteration, but both, of c 's certain^e 1S discovered, throw some light on particular cases.
Oe^^^mstan' Continues Dr. Bright, that ha:maturia takes place under a variety to Scr 'n ConseCes : s?me states of congestion and inflammation, such as often by patina ^.V.ence of intemperance, or after exposure to cold, or subsequent Scftsih Anient Pr?duce hematuria; and this will probably never be followed ^tw,tumor -?Ltlic ^'dney, or, at all events, never to the extent of producing Hi>hagic . ' and of this we may have almost hourly experience. A general Vea ^Se-und n?y of the system will often shew itself by hematuria; in ofth the ,r. Particular circumstances, extensive ecchymosis will be proat ?rgan ^,IS of tlle kidney, but may subside without causing any tumor *he more local causes of hemorrhage, as obstruction to the cir-S 2 l p rjuly1 260 Periscope; or, Circumspective Review, l culation through the heart or even the large viscera of the abdomen, ^ _ but duce slight hematuria, without any enlargement of the kidney -^elf,sl) where a profuse haemorrhage takes place, or a tendency to it shews 1 mischief frequently follows as leads to tumor of the organ. This a ^ is probably not to be considered so much the result of any one /orrn up, y tending to enlargement, as the source from which irritation is se jrritat'on' coagulum forming, and not capable of immediate expulsion, produces -0ingf and assists the deposit or the accumulation of calculus; or, by re gv;erylD' urine in the pelvis, produces inflammation and suppuration there. j0>vblC. stance of hemorrhage which can be fairly traced to the kidney, an \oov the entire blood comes away in a form capable of coagulation, must yflp upon with fear, as likely to lay the foundation for some organic chang ' t# that consequence may be depends rather on the tendency of the sys part, than on the haemorrhage per se.

{gbO.
When hemorrhage occurs in the more-advanced state of the disease* i look to the circumstance of its being pure, or mingled with pus, as imp perb3^t a diagnostic point of view; when it is pure, forming clots which ' co<; moulded to the shape of the passages, if I found a tumor, I sh?u'" ^,ay( grf probable that the kidney was pervaded by cysts, or that, in some ^M obstruction was experienced to the passage of the blood through tne c^ric substance of the kidney; still the diagnosis would be modified by tn be1"!0,) of the tumor: if it were hard, resisting, and chiefly lumbar, I shou confirmed in this belief; and if, in addition to this, I found that the ucoBJplet^', perfectly clear of blood, after the haemorrhage had for some days ^.j, fl subsided, was still albuminous, I should very confidently expect sorD-exej p0?5 generation in the substance of the kidney as I have described, interm blv with granular deposit.
When haemorrhage occurs in smaller quantity, but mingled with puS'. e dep? rally subsiding rather more slowly than the pus, so as to form a fringe-^ on its surface, it probably bespeaks some local bleeding from the Pe'vlS' pending on the presence of a rough calculus, to a small extent laC rubbing the membrane, or more commonly depending on a tendency growths beginning to arise from it." .fl the^'e If small calculi, our author goes on to remark, have been Passev-nh part of the history of a renal tumor, the natural conclusion to w. ^ the/cn is, that some similar formation having taken place within the pelvis . 3 nev, and having been unable to find its way down the ureter, the Pel ^e, ^ irritated either by the calculus or much more likely by the retain^ jjjpl^ pus has accumulated in the cavity and distended it;?but this seldo ^ without pus being actually passed. re^M# If the tumor be hard and insensible, and lodged in the lumbar g|}0r,r^( should incline to the supposition that it was neither enlarged from P0^ of P fungoid growth, and may probably be changed in structure through0 vaded with cysts. . jjy to J If the tumor appear to have increased very quickly, and esp^1 app^vo( grown irregularly, projecting in particular parts, advancing upon i pe'fV towards the scrobiculus cordis, rather than descending towards ^ d>s increasing regularly-towards the mesial line, we conclude tha sjfnp'c is rather a fungoid or malignant growth, than the product 0 ^animation. phosphates, however, are of less easy detection ; but if 'd. and add'SUS^^?n ^at t^ie deposit *s purulent, by pouring off the clear 'UtK0^' andlnS-t0 ^ePos^ a ^ew drops of the liquor potassse or the liquor Jtiu Periscope; or, Circumspective Review. [J"1)'1 e tender age : indeed the kidneys of children are very susceptible of dis functional and organic. In more-advanced age, the obstructions in passages increase, and formidable calculous diseases multiply." r of The cases themselves are twelve in number. The first is one of tu pllratio11 kidney, from numerous cysts found in its substance?the second, of the kidney, from stricture of the urethra, attended with perceptib third, tumor formed by the kidney?the pelvis being distended fourth, tumor from puriform collection in the kidney, first perceived a rition, but apparently depending on the presence of a calculus-^-.^g d"' tumor formed by the left kidney, supposed to be uterine ; the pelvis ^get^ tended with grumous matter, and the substance of the organ su^erlI!?'c kid110'' with the liver, from malignant disease?sixth, tumor formed by t rjfor" dilated with puriform fluid?seventh, tumor of the kidney, with c0P'?Ufth tu1?0 discharge through the urethra, and probably through the bowels?eig formed by the left kidney, discharging pus copiously both by the ur<?tun)of "j the rectum, depending on a large renal calculus?ninth, cerebrifom1 ^iCt? the right kidney ; supposed to be a tumor arising from the concave ^ tl> the liver?tenth, tumor of the kidney from fungoid disease mistal<c spleen.?Death by rupture into the peritoneal cavity?eleventh, ^"un^?s d>sej5 of the kidney, affording the appearance of two tumors?twelfth, fung0 of the glands of the mesentery, resembling enlarged kidney. . .

!fJ f
We must refer the curious to Dr. Bright's paper, should they W.1S yerb'. itself; and where it has been, apparently, almost entirely a purl^cnases from the pelvis;?and this latter is by far the most common in c afford any enlargement of the organ capable of being discovered be ^3^ In these cases, the whole kidney becomes reduced almost to the sta sacculated membranous bag; the lining of the pelvis being brought jaye^ contact with the external tunic, that nothing but a thin and condens ^ ^ the substance of the kidney separates them: but there is still no appar apPj of continuity or suppuration in the substance of the organ, nor ^?e.s fu"^, to have commenced in that way. Frequently, however, after some ti> . to growths spring from the lining membrane; and frequently the te tcC'sP tend and to suppurate is not bounded by the organ itself; and the p?* result is, that an opening is formed into that portion of the colon w , is0 over it. This process, even before the communication is fully ^?^;0n attended with diarrhoea; which, in the already weakened cond'* ujCer?V(I patient, adds greatly to the urgency of the disease; and when the ^ 0l has extended into the intestines, much puriform matter is evacuatedope?'^ times, the tendency seems to be rather to the formation of an exte^,n0f its% I do not remember to have met with a case in which it has opened accord in that way ; but where the fluid has approached so near t1 to lead to the evacuation by the lancet or the trochar, it has aSa^gCape; ^ accumulated. There is at least a third way in which the pus n13^,. js not ,(f that is, by ulceration or rupture into the cavity of the abdomen.
probable that this effusion of pus should take place by ulceratio' > haps, surprising that an individual should have a decided preference particular mode of operating which he has adopted; but it is remarka ^ 0f he should give a sweeping condemnation of a method which has the sanc some of the greatest names in modern surgery. The flap operation lS adapted, no doubt, to some cases than the circular; but there are very ^ | others in which I believe that the latter will be found to be the best, ' must confess that where circumstances will admit of the performance 01 should operate by the circular incision. It has, to my mind, advantag^ tii"c the other method, that more than counterbalance the greater lengtn ^ ^dc which is required for its performance. A better stump, it seems to me, ^0& by it, and the parts heal with quite as much readiness. A patient, fr?nl jg3/< I removed the leg above the knee by the circular operation, in ^ walked out in sixteen days after the amputation, the wound being entirely jjjjj An artificial limb was fitted to the stump, in a few weeks after, and up he has walked with comfort ever since. ?ractic,; It is very well for Mr. Liston to speak roughly, and to denounce this I. or that. "The day is past for any such dogmatism. Methods of p*aC . y a of stand or fall by their intrinsic merits, not by strong opinions expressed ^and man.
The circular operation is preferred by the great majority of surge0 'efy even Malgaigne, bred in the school of Paris, and likely to lean to the flaP tion, confesses the superiority of the circular in its results. ff 3. Fissure of the Rectum.?There is perhaps no surgical operation so much relief as that for fissure of the rectum, and there is hardly any soif that is more painful. It consists in a superficial ulceration of the rectu' 'jeI)gtl>' times extensive, but more often narrow, and rarely more than an inch tV?* It is found more frequently on the sides and posterior part of the g?t' the anterior. It extends down to the sphincter, and can usually be bro & ^ bf view if the patient strains down. When this cannot be done, it can be introducing the finger, though this is attended with great pain. . jg ^ The greatest suffering is experienced at the time of defecation, and i ^ often so severe that the patients are obliged to lie down for some time pain is attributed by Dupuytren to a spasmodic contraction of the sp gS jfl this seems probable from the relief that the division of the sphincter g ^j)these cases before the ulcer heals, and from the fact that the same train toms is sometimes met with when no ulceration can be detected. u[Ccf< reason to think, too, that there is nothing peculiar in the character of111 ^v0r? as it usually heals so readily after the operation ; and this circumstance the opinion that it is often the result of mechanical violence, produc r>'i times by hardened faeces and at others by strong efforts made in Pd ^ p0< It is very certain that it is more frequent in females than in males, an ^ common in those females who have borne children than in those who Dr. Hay ward has found nothing but division of the ulcer and the sp^ fie really effectual. He thinks division from without inwards the best me relates a case; we shall introduce the operation. Report of the Massachusetts Gen. Hospital. 265 Jenun, a*^'na''on> I found just within the margin of the anus, towards the t?uch. TVi?W u'cer' an 'nch or more in length, quite tender and painful to formed' ;n J?6 bowels having been emptied by an enema, the operation was 'n*r?duced i t f?H?wing way. The fore-finger of the left hand having been fP^iticter tin ?rectum, a spear-pointed scalpel was thrust in outside of the 3^een the ^ reached the point of the finger, thus including the sphincter j'tt^rawn th G sca^Pe^ ancl the finger. Both were then simultaneously .I106*! betw e sca'Pe' cutting its way out through the fissure. Lint was introi!!^ed the d6en ?t^le wound, and a compress and a T bandage comj 'ch were res?lng. For two or three days he had slight spasms about the anus, hr?Uble; hi/^ -eve<? ^y anodyne fomentations. But after this period he had no in ^as disch eJec^ons gave him no pain, though the ulcer was not healed, and fespec^^^ fr?m the hospital ' well,' in fourteen days after the operation, s able to resume his ordinary avocations." b!^-Hpfc?'r"For *wo or three Years> in performing the operation re?U^e8orne f Ve n?t uset^ the common hare-lip pins. They are almost always if the10?1 ^eir size, an(l occasionally produce ulceration, and in this way ^fPeared Patients the oedema formed around the puncture and the fluid wthe 0nj Slx*and-thirty hours, but was effused again in three weeks. This &nr E Cat* ass?aSe 'n w^ich there was a prospect of a cure." ^ .r Fe -Dr* Hayward that little is expected from this operation by good r'ty are c 'S .countrY-One or two may have been caught with it, but the ?nvinced that it is " a matter of moonshine." ? ? * It may be useful to learn the results of the experience of the CauSe assac'1usetts Hospital, on the subject of erysipelas. readily produced by those patients who had large suppurating surfaces, others, who were not affected in this way. doubt* Admitting this to be true, and of its truth I think there can be no ^sp'1 obvious dictate of common sense is to change the air in the wards of t:a c0p as often as possible, so as to substitute pure air for that which has ^ iti' taminated. This is not so easily effected as at first it might seem to ? difficult to do it in the spring and autumn, when the weather is sufficie .^ ^6 to enable us to dispense with fires, but at the same time so cool as tore 1^ cofl* windows to be closed at night. It is also difficult in winter, withou ^0|dsumption of a large quantity of fuel, and probably the best ventilator 0$\<P fashioned open fire-place, but every one knows that it is not the most ec -^$0$ mode of warming a room. There can hardly be a doubt that erysipelas more common in those hospitals that are warmed by furnaces than in [q: is are not. The fire is usually allowed to go down at night, the ven frequently closed to keep the apartment agreeably warm, and conseq'J patients must inhale for several hours the foul air.

b^1'
This may not be true in all institutions that are warmed in this way certainly was in the Massachusetts General Hospital. A change in to' foil was made the last autumn ; the ventilators are now so arranged ^ cannot be closed by the patients or nurses ; and to render the ventila ^391 n ?itcport of the Massachusetts Gen. Hospital. 267 " ' hav i^agionG Sjej nothing lead'to the belief that erysipelas is propagated by j.at no fw h no' mean to say that it never spreads in this way, but merely e> that ?i com.e under my observation, either in hospital or private prac-ti^r* Hav ^ i s^Shtest countenance to this notion." ..e adverts Iar ifeems to us to display judgment in his principles of treatment, a ,0tlthe ? ?e extremes advocated and pursued by many?to the bark prac-Proprjp?06 band, and the bleeding on the other. He questions (well he may) f^ients hp ^ e't^ler 'n the great majority of instances. There are but few fe'as *> and remar^s? that will be benefited by bark through all the stages of erysi-!? s?me at tv,?n ?tberhand, though depletion is unquestionably highly useful 0re the t ? ?-nse*' there are not many who will not derive advantage from tonics tar''er> andetIninatl0n disease. lu ^act' they maybe given with advantage ^articularlv t? & ^reater extent, than in almost any other complaint. This is l'ersons f0p ,[Ue the class of subjects that are met with in hospital practice, j^ious most part whose constitutions are impaired or broken down by reatment ofaSC ?-r excess-this we cordially agree with Dr. Hayward. The CUtQstances 5 rysipelas should not be empirical, it should be adapted to the cir-?r ?ver-stim? eac^.case* It is absurd to dole out the same treatment to sickly, I?^Ustand ,ated inhabitants of a large city, which is applied to the case of the ^retice a? c?untryman. Every body knows the ridiculous fallacy of Mr. ^ed an^ -^ttempting to render this distinction absurd, he asked where town ! Arson's ere the country began! as if we practised by Mogg's map or it sign-fl?ad ^ook ? It signifies nothing at what mile-stone the suburb ends, t^titutio es much, nay every thing, whether a man leads the life and has the ^ ever wn?fa London artizan or of a north-country grazier. Mr. Lawrence, 1)088 0r Pat1"18 ^?r bleeding an(l incisions, and he could not listen with calm-^ lence to either facts or arguments against him.
p"shed. a^Us -dm.?Dr. Hayward recommends an operation. It is readily accomt?11168 aM'av'tvf1101119' warm water should be first administered, and when this a Can then K P.ro^aPse(l portion can usually be thrown exterior to the sphincter. i> rie6dle> a e Seized with a double hook, which should be held by an assistant, j. w*th a double ligature, should then be passed under the base of 'tection ae*T P01"tion, the needle cut out, and one string tied firmly in one Titled VtV other in the opposite. The part should then be carefully 1 Pain i!n spbincter, and the ligatures allowed to hang out at the anus.
?. ?Uld be severe, an anodyne enema, or an opiate by the mouth, or both, d'Ve ?n a J1*! ^'"istered. The patient should keep in a horizontal position, and ay after 1 ' liquid diet for a few days, and take a gentle laxative on the second ft ? Hav G ?Perati?n. The ligatures usually separate in from five to ten days, v ?Perati^afd observes, in continuation. It is no unusual thing to find, after j "?h stri^11 Prolapsus and internal hemorrhoids, that the patient is troubled This is of course produced by cicatrization, and JJ '?nt shounS6S rfadiIy overcome by the use of the rectum bougie. If the action f0 ??ntinue to use this occasionally for a length of time after the A^ifiicultv eit^er complaint, there will be much less danger of a return of Mother i * ^ter.
portant means as a preventive, is the daily use of an enema of cold Injection S Sll0.u'(l be thrown up in the morning, just before the usual time for 0vVels with^ it will in most instances produce the desired discharge from the ?ut pain. From a gill to half-a-pint of water is sufficient. The elasticity of the feathers is such, that no danger of m ^der all*1110*1 .Pressure on the part need be entertained, and it will be found fi?1-6 coqid1-m?tion, and to keep the fragments in apposition better than any st cases 1Cf^ aPParatus. The treatment which we have found most success-es^, grg delirium tremens, has been the free use of opium in the early ?^rate us 0r 'V* every two hours, together with nourishing soups, and the th '0n'c antf6 ?^.st'mu^* The latter are generally given in the form of porter, P^pil be an^lsPasmodic tinctures. In the latter stages of the disease, when jje ^Uantitv00?63 .contracted, we either omit, or very considerably diminish, ck." . of opium, and apply large blisters to the back of the head and t)'3, t akltle? labof External Lateral Ligament of the Knee. Cure.?Jno.
hi8at?k of earth^ Setat' 20' Emitted -May 31st. A short time before admission ^ r'6ht l{ne ac* fallen in upon him while at work, striking the outer part of it!,6 ^Ccident w cari7'ng his leg forcibly inwards. The pain at the time of heS&1?a he cn as.8?vere? and all power of motion was at once lost. Upon ad-0f t^^Pl^ed altogether of his knee, which was slightly swollen. The f6(^e uainjur 6|nur an^ tibia could be distinctly traced, and, as well as the patella, the^r' le ' ^P?n raising the limb and holding firmly the lower end of the ev-.extremitt^ Cou'd be pushed considerably inwards, and a separation between ?t, whic^f ?? ^eraur and tibia at the outer side of the joint was very le sk?rtenin d'sappeared upon the force applied to the leg being discontinued. niotion ^?i t^le hmb or crepitus existed, but great pain was caused by the 01 the part.

2/0
Pkriscopk ; or, Circumspective Review. l/11, ]aCeJ In order to preserve the part in a state of perfect rest, the limb was P ^^5 a long fracture-box, and under the use of cold applications, followed y^ eare<lto the knee, the pain abated, and the swelling in a few days Jggree0 Towards the middle of July it was found that there was still an undue je.
lateral motion at the outer side of the knee, and with a view to hasten posit of new matter from the vessels, a blister was applied over this paf improvement followed this, and a second and a third application of tne rt o' was made at short intervals of time, with decided benefit. In the latte p]ic<i> August he was suffered to move about, a soap plaster and a roller being in order to give some support to the knee, and on the 15th of Septefl?"e discharged cured. rrJjg C0? 4. The Application of the Cold-water Syphon to Lacerated Wounds tinued application of cold has been used with benefit in several cases of ^jcb wounds. The following was the mode of application : the pillow VP,0 the injured part is placed being properly protected by oiled silk, and the covered with lint; and, if necessary, the sides of it drawn together with & ^ 0j plaster, one end of a long strip of lint is placed in a basin of cold wat.erattacl>^ a table near to and above the level of the part, while the other end is to the lint laid over the wound. This, acting upon the principle of ,a , 0ff W keeps up a continuous irrigation of the parts, the water being carf'e j up?1 causing another strip to connect the dressings with an empty basin pa ^5"' the floor.
The continuous application of cold in the manner clesC^YCjosse' late been particularly recommended in this class of wounds, by MMyerf Amiens, and Berard, and in hot weather will be found an agreeable a c 0^' effectual means of preventing a too high degree of inflammation and quence, excessive suppuration. \ lab0"1*' 5. Hydrocele cured by Injection of Tincture of Iodine and Water.?A aged 31, had a hydrocele which had commenced at puberty. . ^a^' " After drawing off the fluid, I injected a mixture of tinct' iodine a". in the proportion of one part of the former to seven of the latter. The 1 ^ was suffered to remain but a few minutes, it being withdrawn as s0?n ajo was complained of. The day following the operation a good deal of P^j the inflammation were present; the scrotum was supported by a bag ^rUl9'tjieP8'! patient kept at rest upon his back, on a diminished diet. On the l2tn> had nearly left it, and the part had much diminished in size. On ^ left the house.
Early in August he called to show me his testicle, ^ at that time but little larger than natural, soft, and without pain." f ?J.
6. Varicocele, successfully treated by the Operation of Davat.? Case 1* ajtat. 25, entered July 7th, with circocele of the left side. Examined ^ patient had been using exercise ; the veins of the cord of the left side W ^jc to be nearly of the size of the little finger, and greatly convoluted; tn . appeared sound. The mind of the patient was dejected on account of ^e\m tion, and he complained of severe pain in the loins. The general hea ejW good, the case appeared favourable to a trial of the mode of cure Pr?Jjefer^" Davat. On the 14th, after isolating the vein from the artery and vas ^ (the patient being erect,) I passed an acupuncturing needle through $3$ anterior and posterior parietes of the veins; after which I pushed 1 ^ and forwards in such a way as to make it re-appear at the surface ha ^e3 0 above the place of insertion, after a second time passing through the vessel. The needle was then fixed in this situation by the twis t)e moderately tight. The operation was done almost without pain, and ^ p was afterwards confined to a recumbent position, upon a restricted g po little inflammation was produced till the 18th, when the part bee ?Pera-ting adopted in the above cases appears to mc much pia 3' a^d th / lhe other methods recommended for the cure of varicose ^ ^hen crrfresU^ aff?rd additional proof of the safety and efficacy of the ttwAl'ng the'0y applied. The passing of a needle behind the vein, and ?Ub by M C^Cu^at'on *n it by means of a twisted suture, as recently recom-jw^Uent elpeau, effects a cure by the pressure causing inflammation and the ?f pu Ceratjon? and complete division of the veins ; whereas by the tor, irritCtUr'n^ vesse'> adhesive matter is at once thrown out around ??' Pr?ducing the cure by union by the first intention of its in-( WESTERN LYING-IN HOSPITAL OF DUBLIN. 'n ^ From an able Medical Report, the third, published by Dr. Churchjj^ ^ excellent contemporary of Dublin, we extract the following tables. ^0rl<i on a dispute which has been literally raging of late in the obstetri ^ Whether we shall draw on ourselves the ire of that most irascible^ j,op< and most acrid of accoucheurs, Dr. Hamilton, we do not knownce(^ not. Whatever we may think of his practice, we pray for a safe delivera ^ p his pamphlets. There can be no doubt that his is a crotchet ca ad rem.
. 0{e*c The following tables of labours of a certain length shew the duration stage, and the results to mother and child.  and more successful than usual. Mild purgatives, salts and tartar e? ligh the plentiful use of warm water, and carefully protecting the eye fr? jjes, S? by a shade, was, for the most part, all that was required. A few liest"06^ out of a neighbouring brook, were employed ; but it was found so get them to bite, that but a very limited use was made of them-regar^ . leeches are only permitted by the trustees of the institution, in what are as extreme cases.
Cupping the temples, and blistering, were seldom j0 Under this treatment, it was surprising how rapidly the eyes improv'e the ,l0i instance did the disease become chronic, rendering scarification 01 n5to^\ surface of the eye-lids necessary. Neither were stimulating aPP^car, the ?^tL eye, nor tonics for the general system, indicated in a single instance, y of the ophthalmia. , tr^a 3. Treatment of Dysentery.?"Above fifty cases of dysentery have s"0'! none of which have died ; with the exception of two old persons, g Ji3 refused to take medicine, on the supposition that their time of depa ^ered^ arrived ; and one woman, who had been sick a month before she ^ house, and was in the last stage of exhaustion. The treatment in a 0\\,^ cases consisted of full doses of calomel and opium, followed by c.a^ ? v0 this succeeded by Dover's powder. Twenty grains of calomel, with ^ gj* o of opium, or fifteen grains, with a grain and an half, were given, a eight hours after, an ounce and an half, or two ounces of castor oil ^ nistered.
The opium very speedily relieved the patient from ,eieiac,'etf tormina and tenesmus, procuring several hours' ease; while the calo upon the liver and mucous coat of the bowels, especially the latter, P secretion, thus depleting the congested vessels, and changing morbid10 j,icb j action. Free evacuations were then produced by the castor oil; ,jraS;' morbid contents of the bowels were removed, and farther secretion en After copious purgation, fifteen grains of Dover's powder, allayed t?e^ aCti"^ of the intestinal canal, and acting upon the skin, restored its function 0ft and by determining to the surface, assisted in removing the engorge? ^ inflamed mucous tissue.
, noth' ^ In many instances, this course of treatment effected a cure; an ^1 ^ j farther was required, but attention to diet. In other cases, the ca oUncC repeated, followed by the oil and Dovers' powder. Sometimes an